Friday, July 5, 2013

On a nice sunny day early last week, I set off from Trichy
to Thanjavur to visit the field site of two exciting social ventures. The
build-up was good – the 50-odd kilometres from Trichy to Thanjavur took less
than an hour to cover on the well-maintained four-lane National Highway 67. En
route to the office of Sugha Vazhvu Healthcare (SVH) in Thanjavur town, I
passed streams of older girls walking to high school and college, a vivid testimony
of Tamil Nadu’s impressive social indicators.

My visit started with a useful introductory meeting with the
SVH team. If the ability to attract a
good team is evidence of a successful organization, this meeting was a clear
indicator that SVH is on to a good thing. The SVH team includes a public health
specialist trained at Johns Hopkins, an intern from Yale, doctors, and alumni of
the Young India Fellowship programme. I then got to learn about the financial
inclusion initiative run by Pudhu Aaru Financial Services (PAFS) in the same
district.

The Visit to Alakkudi

After the meeting, we drove down to Alakkudi village where SVH
and PAFS are co-located right on the main street. Visible from a distance is
the wireless communication mast that provides access to the IT hub that provides
the backbone of both these social enterprises.

Healthcare

The SVH micro health centre has a simple design. An open
reception area offers benches for patients to sit, and a Health Extension Worker (HEW) registers patients or updates records. Behind her is a small examination
room. To the right is the doctor’s chamber. Conspicuous in this room are the
laptop on a table in one corner, a big medicine cupboard, and a smaller
examination bed that doubles up as a chair for dental scaling. Overall, quite
neat and unfussy.

I found a few distinctive and impressive features of the SVH
approach.

The first is the emphasis on preventive healthcare. While
patients tend to come to the health centre only when they are sick, SVH tracks community
members to see whether they have any incipient signs of “silent killers” like
cardiovascular disease or cervical cancer. While they take pains to avoid
unnecessary tests, at the same time their focus is on early detection so as to
save patients from expensive and complex curative options later. (SVH has its
own diagnostic facility shared between a set of micro health centres).

The second is the collection and maintenance of data. The
establishment of each micro health centre starts with a community engagement
initiative. Each rural micro health centre has a Health Extension Worker (employed
from the local community) with an android-based phone who visits homes to enroll
community members. Each patient enrolled has a neat bar-coded registration card
that serves as a unique identifier. Since the health record of each patient is
maintained on the health information system of SVH, and updated directly online
each time the patient visits the health centre, SVH has a comprehensive medical
history for each patient who uses its services. At an aggregate level, such
data will be useful for identifying disease patterns and epidemiological
studies over time. (In contrast, Government PHCs still use paper and files; even
today, some of the “best” hospitals in India do not maintain comprehensive, digitized
medical records of their patients).

The third is the push towards evidence-based medical care.
As the doctor speaks to a patient and captures the patient’s symptoms, the
diagnostic process is aided by different menu options on the doctor’s laptop.
These options prompt the doctor on what questions to ask and also ensure that
important possibilities are not left out.

A fourth (related to the third) is the effort to train and
use Ayush (Indian traditional medicine) practitioners as doctors. They tend to
be more grounded and willing to serve in local communities, thus addressing the
problem of retaining doctors in rural settings. Many of them practice as
allopathic doctors anyway, and here they are both trained as well as provided
support (through the online expert system) to do a better job.

Financial Inclusion

While excesses by some black sheep have brought the microfinance
industry under a cloud, there is no doubt that better access to financial
services is essential for people to improve their lives. India’s fragmented
rural demographic makes financial inclusion through the conventional banking
system unviable, and there need to be alternate ways of providing financial
access.

With developments in technology, and new sophisticated
identification systems like Aadhaar being put in place, there is optimism about
the future of financial inclusion. In the meantime, several efforts are afoot
to solve this problem.

PAFS represents one such initiative. PAFS brings a “wealth
management” approach to rural financial inclusion. If you have ever dealt with
one of the urban wealth management advisory companies, you know what this means
– it usually starts with a listing of your assets (and liabilities) and your
income. It then moves on to understanding your aspirations, financial goals,
and appetite for risk. It then puts in place an investment plan as to how you
can achieve your goals and aspirations consistent with your risk appetite.

The PAFS template follows a similar approach. It has four
stages – Plan, Grow, Protect and Diversify. It is IT-enabled with
easy-to-follow templates that allow the PAFS staff to capture and visualize the
needs of each of their clients. PAFS is not a bank or an NBFC, but works on
behalf of banks under the banking correspondent framework. I saw several women
waiting patiently for their turn at the PAFS office in Alakkudi.

Some interesting features that I saw – a suggestion/complaint
box in which the customer has only to drop a slip with her mobile number – PAFS
management will then call her back to understand her problem. This probably
suits semi-literate customers well – they can write their names and phone
numbers, but may struggle to write a detailed feedback note.

The whole PAFS approach is neatly depicted on some graphics that are fixed neatly on the wall, thereby ensuring transparency of the process.

In Conclusion…

Having seen both SVH and PAFS in action, I would rate both
of them high on effectiveness. But what I am not sure about is the financial
viability of these models. I am not privy to the numbers, but the cost of some
of the basic infrastructure like a dedicated communication link can’t be low. The
cost of the highly educated team behind SVH must also be very high though I
guess this could be spread across a large network once the model is scaled up. Since
PAFS is not a bank or NBFC, it has to manage not on spread but on the
commission paid by the bank for which it is a correspondent.

But, I imagine that with some financial experts behind these
ventures (Nachiket Mor, former Deputy MD of ICICI Bank, is one of the driving forces),
they know what they are doing! SVH is part of a network of organizations under
the umbrella of the IKP Trust, and works in close conjunction with the IKP
Centre for Technologies in Public Health (ICTPH).

I particularly liked the simplicity, and integration of
people and technology in the SVH model. I hope they are able to strengthen the
links with public health and preventive healthcare further. In recent years,
there has been too much emphasis on curative health, particularly in expensive tertiary
care hospitals in cities. Some state governments like Andhra Pradesh are now
paying out huge sums of money for treatment of their citizens in these
hospitals, and I can’t see how this will be sustainable over time particularly
with the predicted increase in “lifestyle” diseases.